Sore back? Your bad posture may not be to blame after all, experts say

If you do a web search for “back pain and posture,” you’ll be met with articles about the effects of poor posture on the body, guides telling you how to reduce your back pain with posture exercises, and ads for all kinds of posture-correcting back braces and ergonomic devices.

It seems to make sense. After all, we’ve been told that good posture makes us healthier and less susceptible to injury, and that bad posture leads to aches and pains down the line. 

But several researchers and clinicians say that there’s not much evidence to support commonly held beliefs that bad posture leads to pain.

“As a young physiotherapist, I realized there was very little research evidence,” said Peter O’Sullivan, a professor of musculoskeletal physiotherapy at Curtin University in Perth, Australia.

O’Sullivan has spent the last two decades studying back pain, its causes and how to manage it. Back pain is the leading cause of disability worldwide, according to the World Health Organization, which predicts that by 2050, there will be 843 million cases of lower back pain globally.

He says he first became interested in the connection between posture and back pain after a ski injury led him to experience excruciating chronic back pain. He started holding himself more straight and rigid, thinking it would help protect his back.

But “my pain just got worse and worse and worse,” he said.

Eventually, O’Sullivan started relaxing his body and found that his pain slowly subsided.

“Personal experience showed me I got into real trouble when I was trying to hold these tense, upright positions,” he said.

In a paper published last year in The Lancet, O’Sullivan and his team described a clinical trial where people with disabling back pain were explicitly taught not to protect their back. Instead they were given cognitive functional therapy exercises, such as reflecting on their pain beliefs, practising relaxation techniques, moving their bodies naturally, and developing healthy lifestyle behaviours around sleep and diet.

After a year, O’Sullivan says, participants who were given cognitive functional therapy experienced less pain and disability compared to those who were only given usual care, such as physiotherapy, massage and medicines.

“They had more positive beliefs about their back, they were less frightened [and] they were more confident when we taught them not to protect their bodies,” he said.

Posture panic takes hold

Our obsession with perfecting posture is not new. 

University of Pennsylvania medical historian Beth Linker delves into the history of what she calls “the poor posture epidemic” in her book Slouch: Posture Panic in Modern America.

“You can find plenty of evidence to suggest that we are obsessed with posture,” Linker said in an interview with The Sunday Magazine’s Piya Chattopadhyay.

“And it’s not only the obsession — it’s the assumption that it’s obviously right, that we have to somehow discipline our posture and that that will lead to better health, or it will prevent back pain.”

Associating slouching with negative character traits like laziness or slothfulness has been around for a long time, Linker says. But in the 20th century, these ideas about how someone carries themself were “scientized and medicalized in this way [that] seemed to make that even more entrenched.” 

In 1914, the American Posture League was founded by educator Jessie Bancroft. It promoted the ideal of “plumb-line posture” — where ears, shoulders, hips, knees and ankles should stack vertically along an imaginary line. 

Around the same time, many U.S. universities were implementing posture exams — which included taking photographs of undressed freshmen — to measure students’ health and physical well being. 

Posture scientists also adhered to “soft eugenics,” Linker said.

“They did not concern themselves with sterilization, about controlling reproduction as hard eugenicists would,” she said. “But they did believe that if we didn’t pay attention to the posture of the citizenry that there would be a potential de-evolution.”

Meanwhile, the market for posture-correcting devices, which Linker says continues to this day, really took off with the 20th-century posture scare, even though she says there’s little “solid evidence to show that it really is worth what we’re paying for.”

But what’s been missing in all of these concerns about slouching is solid evidence, says Linker, who also has clinical experience as a physical therapist.

“We need more research into it rather than just accepting the fact that it’s just automatically obvious that we have to all maintain our posture,” she said.

What even is ‘good’ posture?

Trying to define “good” posture is elusive, says Krista Madsen, an associate professor of kinesiology at McMaster University. 

“There can’t be one good posture by the fact that we all have different shapes and sizes and distributions of the way our bodies are made,” Madsen said.

“It makes sense that there should be some variety or some variability in the way we stand, or in the way we sit.”

When she trains her students how to do posture assessments on other people, she tells them to simply describe what they see and not to assign judgments of whether it’s “good” or “bad.”

While some researchers question claims that bad posture causes pain, Madsen says they can still be related — and may be pointing to another issue.

Pain is complex and can be caused by different factors, including stress, trauma, anxiety and depression, experts say. These same things can also affect the way someone carries their body.

“Maybe that pain isn’t really because of the slump, but maybe that pain is attached to the anxiety and depression,” Madsen said.

She admits that there may be other reasons people want to develop a more upright posture, like projecting an air of confidence. She recommends a thoughtfully designed exercise program that includes resistance exercise and mobility work, or simply more daily physical activity, which would be beneficial regardless of posture.

But Madsen says that if you’re not actually experiencing any pain or issues, and your body seems to be functioning well, “then maybe you’re in your ideal posture.”

For those who do experience chronic back pain — and have ruled out serious issues like fractures, infections or cancer — O’Sullivan recommends determining if it may be driven by major stressors, past traumas or other lifestyle factors like not getting enough sleep or physical activity.

“Pain’s complicated. It’s multifactorial,” he said. “And the best way to target it is to identify what factors are relevant for that person and then target them.”